Do Addicts Have Too Much Empathy?
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I have this shocking statement I sometimes make in my lectures: “Heroin addicts are sweet people.”

I say this partly because I’m an addict myself and I tend to make hyperbolic statements for their emotional impact (not my best quality). But I also do it to push back against the tired trope that addiction can be reduced to a personality disorder. This is what I learned in medical school: put bluntly, addicts are sociopaths.

This has not been my experience. When I sit down with a person struggling with addiction, when I listen to him or her as an equal, I do not hear the narrative of the sociopath: a person who doesn’t care about the feelings in those around them. In addicts - heroin addicts especially - I hear people who are exquisitely sensitive to the feelings in those around them.

So, yeah, I’ll say it: heroin addicts are sweet people.

Different audiences react in different ways. Prosecutors squirm. Others roll their eyes. But if there is a mother of a heroin addict in the room, and the lighting is just right, I can see her eyes fill with tears.

She has always known her child to feel deeply, to be capable of a keen empathy. It is almost a superpower that addicts possess. They are plugged into the pain of the world. And bravely, tragically, they try to take on that pain. It costs some their lives.

On the other hand, if I’m truthful, every fifth parent of a heroin addict says quite the opposite: “Uh, no. He’s always been kind of a selfish jerk.”

It’s hard to hear, but often just as true. I can call addicts sweet people all I want, but I do them no service if I don’t admit that these feeling people can act unfeelingly.

So which is it? Are addicts uniquely empathic? Or commonly sociopathic?

Where and how do addiction and empathy and recovery meet?

The Three Components of Empathy

Those who research empathy will tell you it consists of three components:

Shared affect - the ability to share the feelings of another.

Empathic concern - my motivation to comfort another’s pain.

Perspective taking - can I see the world through the eyes of another?

This is my theory about empathy and addiction: Shared affect and empathic concern are too strong in addicts, and the third is impaired. So maybe what I’m seeing isn’t so much an enhanced capacity for empathy but a collapse of the construct of empathy.

The brain tries to put all three components together but fails. So we see the classic addict paradox:

They are people who see themselves as uniquely sensitive but are blind to the ways in which they hurt the people they care about. They can’t see it.

This is the least attractive, and most destructive, symptom of addiction.

But it is also the most repairable, and the task of my recovery is to re-calibrate my capacity for empathy.

Reconstructing Empathy through Recovery

The first step in reconstructing empathy would be to stop getting high. Intoxicants, especially opioids, wreak havoc with empathy because they disrupt my ability to accurately feel pain.

The areas of my brain that process the pain I feel are also those that are active when I observe pain felt by others. A recent study showed that taking a single Tylenol can decrease one’s capacity for empathy. So imagine what taking heroin can do.

With chronic use, opioids stop relieving pain and actually start making pain worse. They trade analgesia for hyper-algesia. Everything hurts, and the brain does not distinguish very well between physical pain and emotional pain. If the purpose of pain is to guard against further injury an opioid addict is also hypersensitive to emotional pain.

The eminent neuroscientist George Koob has even coined a new word for this phenomenon: hyperkatifeia. It is the residual hypersensitivity to emotional distress, including an increase in the intensity of emotional distress that can persist long into abstinence.

Perhaps hyperalgesia and hyperkatifeia represent an overdrive of the shared affect component of empathy. To cope with this increased sensitivity to pain - mine, or yours - I might resort to increased opioid use or simple avoidance strategies. It may be that the second component of empathy - empathic concern - is not so much an enhanced empathy as it is an attempt to avoid intensely felt pain where the ability to distinguish self from other is compromised. It is less about compassion and more about codependency.

If the shared affect and empathic concern components of empathy are too strong in addicts, then perspective taking is the component that isn’t strong enough.

Empathy and the Mind/Body Connection

One of the major discoveries in neuroscience over the last two decades is the finding that much of what we call “mood” starts out not in the brain, but as signals sent to the brain by a myriad of systems in the body.

This is known as interoception: my awareness of signals coming from my body. Heartbeat, breathing, digestion, even blood glucose level— each of these systems send information to the brain. This information usually falls outside conscious awareness, although I can train myself to become conscious - or mindful – of these signals.

So, the second thing I can do to recalibrate my capacity for empathy is to improve my interceptive awareness. Interoceptive signaling undergirds emotion, and improved interoceptive awareness improves emotional regulation and the quality of decision-making.

When interoceptive awareness fails - known as alexithymia - my feelings become muddled in a kind of emotional synesthesia. Sadness becomes anger. I mistake hunger, anger, and sleepiness for drug craving. If I suffer from alexithymia, my emotions and choices suffer. This is common to several mental health disorders: schizophrenia, autism spectrum disorders, and addiction.

The part of my brain that coordinates interoceptive awareness is known as the Insular Cortex (IC). This is where I attach my body to my consciousness. Intense interest in the IC began after Naqvi published a case series in which heavy smokers who had sustained damage in this part of the brain simply forgot they were smokers. In fact, it was easy for them to quit - they didn't even go through nicotine withdrawal. Today, the IC is believed to be critical in craving brain states.

Another part of my brain - the Anterior Cingulate Cortex (ACC) – links interoception to self-awareness and social cognition. The ACC serves as an error detection system sensitive to social context. It feeds errors I make back to me, in effect telling me “you did that wrong,” and helps me correct my behavior.

One kind of error the ACC picks up on is social cues, so this is where I see myself through the eyes of others. If my ACC fails I won’t be able to see how my addiction hurts those around me. My capacity for perspective taking – so critical for accurate empathy - is shot. This is a petrifying impairment for a person who considers themselves sensitive to the feelings of others and yet is, in reality, patently and blindly insensitive.

If confronted with the discrepancy between the way I see myself and others see me, this may precipitate a crisis that can lead to a “moment of clarity” and recovery or a flood of shame that powers further retreat into intoxicated avoidance. It takes a skilled therapist and/or wise sponsor to deftly negotiate this crisis - to hold up the mirror at just the right time and angle.

So accurate empathy and proper boundaries between self and other depend on good interoceptive awareness and properly calibrated social functioning. Presently, there is great excitement about and research into the power of contemplative practices and mindfulness-base therapies such as Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT) to improve empathy and recovery from addiction.

It is clear, too, how techniques such as Neurofeedback and Somatic Experiencing can improve interoceptive awareness, thus improving emotional regulation and decision making. These therapies and techniques play a role in recovery in ways that mere opioid substitution may never be able to achieve.

It may not be true that addicts are more empathic, but they are surely sensitive in ways that the casual observer may not appreciate. If, as part of recovery, we learn to control this capacity, that sensitivity and accurate empathy could be of great value to others.

Addicts can become some of the most gifted therapists, nurses and doctors you would ever care to meet - once we understand where the pain of the world ends and our pain begins, and have the wisdom to know the difference.